A New and Rare Presentation of Unilateral Recurrent Laryngeal Nerve Palsy in a COVID-19 Patient With No Recent History of Endotracheal Intubation

The Coronavirus disease 2019 (COVID-19) infection has classical symptoms of high fevers, diarrhea, cough, and dyspnea; however, there are cases recording more unconventional features. In this case report, we will discuss recurrent laryngeal nerve palsy as a new and unusual presentation of COVID-19. The patient was a 58-year-old African American male with a history of hypertension, type-2 diabetes mellitus, and obstructive sleep apnea presenting with dyspnea, fatigue, and nausea. The patient was initially admitted to the medical intensive care unit (MICU) for acute hypoxic respiratory failure and completed intravenous Remdesivir for COVID-19. He never got intubated during the ICU stay and his condition improved on the 34th day of admission. However, two weeks later the patient suddenly developed hoarseness of voice. A bedside laryngoscopy revealed a left-sided vocal cord paralysis but patent airway. The computed tomography (CT) scan of the neck did not show any abnormalities, including any impinging masses or structures. The patient did not have any recent intubations to suggest the paralysis was due to traumatic injury, thus favoring that his neurologic injury was likely a post-viral symptom. One possible pathophysiology would be the invasion of nerve fibers (peripheral or cranial nerves) by the virus using the same mechanism as seen in alveolar cells and finally destroying them. Another hypothesis would be the inflammatory response of the host immune system affecting the peripheral and cranial nerves. Therefore, the potential association between neuro-invasiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the recurrent laryngeal nerve palsy resulting in the vocal cord paralysis should be considered and more studies need to be conducted for better understanding.